Hospitals are their specialty

Dr. Bruce Covner treated patient George Randall last week at Scripps Memorial Hospital-La Jolla with Randall’s wife, Doris, at his bedside. Covner is a hospitalist, a physician who cares exclusively for hospitalized patients in place of their primary-care physicians.

K.C. Alfred

Dr. Bruce Covner treated patient George Randall last week at Scripps Memorial Hospital-La Jolla with Randall’s wife, Doris, at his bedside. Covner is a hospitalist, a physician who cares exclusively for hospitalized patients in place of their primary-care physicians.

Dr. Bruce Covner treated patient George Randall last week at Scripps Memorial Hospital-La Jolla with Randall’s wife, Doris, at his bedside. Covner is a hospitalist, a physician who cares exclusively for hospitalized patients in place of their primary-care physicians. (K.C. Alfred)

Dr. Bruce Covner is a hospitalist, a new breed of physician who cares exclusively for hospitalized patients in place of their primary-care physicians. K.C. Alfred / Union-Tribune

Covner asked the man about his pain. He checked the patient’s lungs with a stethoscope. He reviewed the list of tests ordered before the operation.

“What’s the matter with the food around here?” the patient said.

“You don’t have any,” Covner quipped.

“You’re right,” the man replied with a grin.

The lighthearted exchange suggested long-term acquaintance. But this doctor had just met the patient a few hours earlier.

Covner is a hospitalist, a new breed of physician who cares exclusively for hospitalized patients in place of their primary-care physicians.

The ranks of hospitalists, a rarity just a few years ago, are expanding quickly. In San Diego County, more than 140 hospitalists tend to patients at 13 of the region’s 20 medical centers.

They’re welcomed by other doctors, hospital administrators and patients.

Primary-care physicians don’t have to break away from their hectic office schedules to make hospital rounds. Patients seen by hospitalists tend to suffer fewer complications, go home sooner and cost less money to treat overall, several studies have shown.

Hospitalists are on the job throughout the day, so they can quickly respond to patients’ questions, consult with family members, adjust medications and sign off on discharges.

“They’re better at what they do just by virtue of doing it day in and day out,” said Gerald Bracht, chief administrative officer at Palomar Medical Center in Escondido.

But hospitalists still face a major challenge — making sure there’s minimal to no interruption in care as patients leave the hospital and return to the oversight of their regular physicians. Disruptions in treatment are a major reason for hospital readmissions, according to Medicare.

Hospital medicine has become the fastest-growing health specialty, according to the Society of Hospital Medicine. Nearly 28,000 hospitalists now work at more than half of the nation’s medical centers, including prestigious facilities such as the Mayo Clinic, Cleveland Clinic and Harvard University’s Brigham and Women’s Hospital.

More than 82 percent of hospitalists have a background in general internal medicine, the Society of Hospital Medicine found in a 2008 survey. The average hospitalist is 38 and earns $193,000 annually.

In their role as main caregiver, hospitalists typically collaborate with specialists — surgeons, cardiologists and orthopedists. They usually take care of 22 patients per shift, according to a 2009 survey conducted for Today’s Hospitalist magazine.

The hospitalist movement’s dramatic growth was documented this year by researchers from the University of Texas. They found that 19 percent of internists in the United States classified themselves as hospitalists in 2006, up from 6 percent in 1995. During the same period, the portion of Medicare patients treated by hospitalists rose from 9 percent to 37 percent.

Those figures are even more eye-popping when considering that hospital medicine didn’t exist as a specialty until the early 1990s and its practitioners didn’t have a name until 1996, when Dr. Robert Wachter used the “hospitalist” label for an article in The New England Journal of Medicine.

As they did in other parts of the country, hospitalists emerged in San Diego County after internists and family practitioners found it increasingly difficult to make hospital rounds because of their burgeoning patient loads at the office.

The situation became a crisis in 1999 at Palomar Medical Center when overworked primary-care physicians threatened to give up their privileges to admit and treat patients there, Bracht said.

“Physicians have to earn a living, and they earn a living by seeing patients in the office,” he said.

Palomar administrators responded by creating an in-house physician service made up of doctors contracted through Neighborhood Healthcare, a community clinic system in North County.

Early on, hospital medicine had its share of skeptics.

Patient advocates feared that quality of care would drop because temporary doctors might lack full knowledge of a patient’s medical history. But studies comparing hospitalists to primary-care physicians have allayed those concerns.

Some of the most convincing evidence came in a December 2007 report in The New England Journal of Medicine. The authors of that study found that care by hospitalists shaved about half a day off an average four-day hospital stay without producing an increase in deaths or readmissions.

In an August study published by the Archives of Internal Medicine, researchers from Massachusetts General Hospital in Boston looked at 3,619 hospitals and concluded that those with hospitalists did a better job treating heart attacks and pneumonia.

“Those things you do all the time become second nature. Instead of seeing a pneumonia patient once a month, I see one every day,” said Dr. Mark O’Brien, a hospitalist at Tri-City Medical Center in Oceanside.

Despite the positives of hospital medicine, handing off discharged patients from a temporary caregiver to their regular physicians continues to be fraught with risk.

Reports about the patients’ hospital stays can get lost or delayed during the transfer, especially when they’re sent by fax or mail. Patients might ignore instructions for medication and follow-up doctor appointments. Complications that surface after discharge could go untreated until they become severe.

Those issues are compounded when patients lack insurance or a primary-care physician.

“That’s the greatest challenge in hospitalist medicine — not dropping the ball,” O’Brien said. “We’re working very hard on that.”

Some hospitalist groups also hire nurses to serve as case managers who schedule follow-up visits before discharge, call patients to remind them about appointments and confirm that the first outpatient visit was kept.

Back at Scripps Memorial Hospital-La Jolla, Covner made a final visit to a female patient before her discharge. He wrote a note in her chart about calling her primary doctor and giving an update on the case.

The 55-year-old woman had come to the emergency room the night before with a migraine. She was admitted after tests showed that her diabetes was dangerously out of control.

Ensuring that she receives follow-up care will be critical, Covner said.